Aust. N.Z. J . Surg. (1996) 66, 133

EDITORIAL COMMENT

WHO MANAGES BREAST CANCER?

The article in this month’s journal by Chew et ol. ‘Mammo- graphically negative breast cancer at the Strathfield Breast Centre” shows what can be achieved by a dedicated uni t whose aim is to provide a high quality breast service. The results are not only a credit to their standards, they also provide an example of surgical audit and how it can be used to evaluate one’s practice.

The article raises the important issue of who should manage breast cancer. Most breast lumps are managed outside of such specialized units. Can equally good results be obtained by prac- titioners working as individuals? To what extent is the role of the general surgeon in breast cancer management being eroded by the emergence of the ‘breast physician’, by the National Programme for the Early Detection of Breast Cancer and its Assessment Centre and by specialist units such as the Strath- field Breast Centre? Is the trend to these specialist centres appropriate?

Whatever the answers to these questions, the bottom line is that the system must be in the best interests of the women who seek help. We must aim to provide a prompt, accurate diagnosis and if malignant, early effective treatment to ensure that patients return to a normal life as soon as possible with the best achievable chance of long-term disease-free survival. The woman’s physical and psychological well-being must always be to the forefront. For the surgeon working as an individual outside of a multidisciplinary breast centre, there are consid- erable advantages both to the surgeon and to hidher patients by working in close liaison with radiologists, pathologists, counsellors, medical oncologists, radiotherapists and plastic surgeons. Indeed, formalizing these individuals into a specific team may prove to be the ideal.

Another issue is the provision and analysis of data in relation to breast cancer management in Australia. While there are some studies documenting the practice of groups such as the Strathfield Breast Centre, there have been very few studies documenting what happens in a population regarding the man- agement of breast cancer. The Western Australian statewide survey of all cases of breast cancer in 1989 is one of the few examples where this has taken place.*-.’ This study showed, for example, that only 65.5% of breast cancers were subject to needle biopsy but with an accuracy of 94.2%, only 31.3% had a breast conserving approach to treatment and 92% of women with positive nodes had adjuvant systemic therapy. Such data are essential as a monitor of current practice and as a basis

against which future surveys can be assessed. The study is cur- rently being repeated for 1994 and the National Breast Cancer Centre is presently seeking expressions of interest to undertake a nationwide survey. For the individual surgeon who practises in the management of breast cancer, he/she should regularly audit hidher work to ascertain things such as accuracy of diag- nosis, that he/she is achieving a satisfactorily low benign to malignant biopsy ratio for mammographic lesions, that a breast conservation rate is achieved which matches acceptable stan- dards (probably in the order of two out of three cancers being managed conservatively) and that patients are being given the best chance of long-term survival by appropriate adjuvant sys- temic therapy. It has been quite reasonably argued that this latter objective may be best met by including as many patients as possible in controlled clinical trials, where the treatments offered will be, at minimum, the state of the art.

Finally, the management of breast cancer is rapidly under- going evolution and in the change it is easy to lose sight of the fact that our paramount aim should be the best care of the patient. It is too easy to allow politics and self-interest to influence planning decisions. The provision of accurate data, both by population studies and individual audit, is essential in monitoring to ensure that the best care is in fact being achieved.

REFERENCES 1. Chew SB, Hughes M, Kennedy C et a l . Mammographically

negative breast cancer at the Strathfield Breast Centre. Ausr. N.Z. J . Surg. 1996; 66: 134-7.

2. Jamrozik K, Byrne MJ, Fitzgerald CJ et a l . Breast cancer in Western Australia in 1989: I. Presentation. Aust. N.Z. J. Surg.

3. Byrne MJ, Jamrozik K, Parsons RW et a l . Breast cancer in Western Australia in 1989: 11. Diagnosis and primary manage- ment. Aust. N.Z. J . Surg. 1993; 63: 624-9.

4. Sterrett G, Harvey J, Parsons RW et a l . Breast cancer in Western Australia in 1989: 111. Accuracy of FNA cytology in diagnosis. Aust. N.Z. J . Surg. 1994; 64: 745-9.

5. Harvey JM, Sterrett GF, Parsons RW et a l . Breast cancer in Western Australia in 1989: IV. Summary of histopathological assessment in 655 cases. Pathology 1995; 27: 12-17.

1993; 63: 617-23.

Mount Hospital Medical Centre Perth Western Australia

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